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Oyster Shell-Like Skin Lesions in a Young Man

  • Jia-Wei Liu
    Affiliations
    Department of Dermatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, National Clinical Research Center for Skin and Immune Diseases, Beijing, P.R. China
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  • Dong-Lai Ma
    Correspondence
    Correspondence: Address to Dong-Lai Ma, MD, Department of Dermatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, P.R. China.
    Affiliations
    Department of Dermatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, National Clinical Research Center for Skin and Immune Diseases, Beijing, P.R. China
    Search for articles by this author
      An otherwise healthy 30-year-old man presented with oyster shell-like skin lesions (Figure 1) on his scalp, face, trunk, arms, and legs of 1 month’s duration. He denied excessive alcohol ingestion or drug use. Three months ago, he had a high-risk sexual exposure. Physical examination revealed condylomata lata (Supplemental Figure 1, available online at http://www.mayoclinicproceedings.org) in the perineal and perianal areas. Skin biopsy revealed a dense infiltrate of lymphocytes, plasma cells, and neutrophils in the dermis. The presentation of condylomata lata and marked plasma-cell infiltration on histological examination raised the possibility of secondary syphilis. Warthin-starry stain demonstrated the presence of syphilis spirochetes (Figure 2). Rapid plasma reagin (RPR) titres were 1:32, and treponema pallidum hemagglutination (TPHA) was reactive. A diagnosis of rupioid secondary syphilis was made. Human immunodeficiency virus (HIV) serology results were negative. The patient was treated with 3 doses of benzathine penicillin G (2.4 million units per week) with rapid resolution of cutaneous lesions within 3 weeks without scarring (Supplemental Figure 2). Repeat RPR titer decreased to 1:8 after 6 months.
      Figure thumbnail gr1
      Figure 1Multiple erythematous plaques with conical, oyster shell-like, dirty-appearing, hyperkeratotic crusts on the scalp and face.
      Figure thumbnail gr2
      Figure 2Syphilis spirochetes demonstrated with Warthin-starry stain.
      Rupioid syphilis classically affects those with compromised immune conditions, such as malnourishment and alcoholism; injection users, HIV carriers, and patients with AIDS are also at risk.
      • Requena C.B.
      • Orasmo C.R.
      • Ocanha J.P.
      • Barraviera S.R.
      • Marques M.E.
      • Marques S.A.
      Malignant syphilis in an immunocompetent female patient.
      In rare cases, it can also appear in immunocompetent patients, as in our case. Attention should be paid to prevent secondary infection when examining skin lesions. First-choice treatment is 3 consecutive weekly intramuscular injections of benzathine penicillin. Intravenous penicillin G for 14 to 21 days needs to be considered if the patient is HIV-coinfected.
      • Requena C.B.
      • Orasmo C.R.
      • Ocanha J.P.
      • Barraviera S.R.
      • Marques M.E.
      • Marques S.A.
      Malignant syphilis in an immunocompetent female patient.
      ,
      • dos Santos T.R.
      • de Castro I.J.
      • Dahia M.M.
      • et al.
      Malignant syphilis in an AIDS patient.
      Treatment can cause severe Jarisch-Herxheimer reaction.
      • Requena C.B.
      • Orasmo C.R.
      • Ocanha J.P.
      • Barraviera S.R.
      • Marques M.E.
      • Marques S.A.
      Malignant syphilis in an immunocompetent female patient.

      Supplemental Online Material

      Figure thumbnail figs1
      Supplemental Figure 1Condylomata lata in the perianal areas.
      Figure thumbnail figs2
      Supplemental Figure 2The skin lesion resolved after 3 weeks' treatment with benzathine penicillin G.

      References

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        • Ocanha J.P.
        • Barraviera S.R.
        • Marques M.E.
        • Marques S.A.
        Malignant syphilis in an immunocompetent female patient.
        An Bras Dermatol. 2014; 89: 970-972
        • dos Santos T.R.
        • de Castro I.J.
        • Dahia M.M.
        • et al.
        Malignant syphilis in an AIDS patient.
        Infection. 2015; 43: 231-236